Name : _________________________________ Credentials : ________

Address : ________________________________________________________

          ________________________________________________________

          ________________________________________________________

Home Phone : ______________________ Home Fax : ___________________

Employer : _______________________________________________________

   Title : _______________________________________________________

 Address : _______________________________________________________

           _______________________________________________________

           _______________________________________________________

Work Phone : ______________________ Work Fax : ___________________

Email Address : __________________________________________________

Preferred mailing address :  __ Home __ Work

Please indicate which 2 special interest groups you would like to 
  join:

  __ Administrative/management                 __ Gerontology

  __ Admissions liaison                        __ Home health care

  __ Advanced Practice Nurses                  __ Pain

  __ Educators                                 __ Pediatrics

  __ Case management/insurance/consulting      __ Researcher

  __ Staff nurse                               __ Subacute care


Note: Occasionally, ARN sells its membership list to agencies and
companies whose products or services may be of interest to
rehabilitation nurses. The ARN membership directory is also
available for purchase.  Please indicate if you do not wish to
have your name sold or provided as part of ARN's mailing list
and/or directory.

  __  I do not want my name sold or provided as part of ARN's 
      mailing list, but I DO wish it to be published in the 
      directory.

  __  I do not want my name sold or provided as part of ARN's 
      mailing list, and I DO NOT wish it to be published in 
      the directory.

  Recruited by: ______________________________________________








Please accept my application to join the following category:

 __ Voting member (RN) ..................................  $100.00
 __ Non-voting member ...................................  $100.00
 __ Corporate or facility member ........................ $2000.00

                                         * Chapter Dues : ________

                                           Chapter Name : ________
        
                                                  TOTAL : ________

               * ARN membership is required for chapter membership
		 Listing of Local Chapters
    
Method of payment:  __ Master Card  __ VISA

  Account Number : _________________________________________________

 Expiration Date : ____________________


Signature : __________________________________________ Date : ______